Pilot Debrief

BEECH C23 near Middleburg, FL — 2021-04-28

Final reportERA21FA194
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Date
2021-04-28
Location
Middleburg, FL, USA
Airport
FL13
Aircraft
BEECH C23
Registration
N6009U
Category
Airplane
Highest injury
Fatal
Fatalities
3
Phase of flight
Takeoff roll

Probable cause

The pilot's decision to depart from a soft grass runway with a tailwind, which resulted in an increased takeoff distance and subsequent impact with trees during the initial climb.

NTSB narrative

The pilot and two passengers were departing from a grass runway. The grass was several inches high and the ground was soft. There were no eyewitnesses to the accident; however, examination of wheel impressions left in the soft soil of the runway revealed that the airplane became airborne about 2,300 ft down the 3,700-ft-long runway and impacted 70- to 80-ft-tall trees about 800 ft past the runway end. Examination of the wreckage revealed no evidence of mechanical malfunctions with the airframe or engine that would have precluded normal operation. A witness who arrived at the accident site about 30 minutes after the accident, and a nearby weather observation around the time of the accident, indicated that the pilot likely departed with a tailwind. Review of the airplane’s takeoff performance chart indicated that, on a grass runway, the airplane’s predicted ground roll would be about 1,285 ft and about 2,151 ft was required to clear a 50-ft obstacle; however, the chart was based on the runway being dry, the grass short, and no wind. Based on the available information, it is likely that the pilot failed to account for the decreased takeoff performance due to the runway condition and the tailwind, which both would have increased required takeoff distance. Toxicology testing of specimens from the pilot detected the non-impairing local anesthetic medication lidocaine and the high blood pressure medication valsartan in blood and urine. It is unlikely that the pilot’s medical conditions or medications were factors in the accident. Toxicology testing of specimens from the pilot-rated passenger revealed the anti-anxiety medication alprazolam at 8 ng/mL in heart blood and in liver tissue. The antidepressant sertraline and its metabolite desmethylsertraline were detected in heart blood and liver tissue. The over-the-counter motion sickness medication meclizine was detected in liver. While it is unknown how well these conditions were controlled or if the pilot-rated passenger experienced any impairing side effects, the effects from the use of these medications would not have influenced the outcome of the takeoff, and it is unlikely that his anxiety or depression or the effects from his use of medication contributed to the accident.

Analysis

Primary failure mode
Controlled flight into terrain
First missed decision gate
Properly assess takeoff conditions including tailwind and soft runway.

NTSB coding

Evidence available

  • Photos
  • 13 docket documents
View NTSB final reportView NTSB docket

Docket documents13

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